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D e Moe., n n o d o <br />`s' n <br />DEMENNO / KERDOON'S LABORATORY IS CERTIFIED BY THE CALIFORNIA DEPARTMENT OF HEALTH <br />SERVICES ENVIRCNIENTAL LABORATORY ACCREDITATION PROGRAM ( ELAP) CERT. 4 2031 <br />GENERATOR'S WASTE PROFILE WORKSHEET <br />GENERATOR'S INFORMATION <br />A. <br />GENERATOR'S NAME <br />B. <br />EPA ID# (f /A L_ <br />1,4 -3 L- <br />C. <br />GENERATOR'S ADDRESS Z Z C '^' i"` •� +� '%��` <br />yD. <br />PHONE 14 <br />-- clod C' <br />E. <br />CITY, STATE, ZIP c k �cxl <br />F. <br />GENERATOR CONTACT �= +� L'`1`I "re <br />G. <br />TITLE <br />H. <br />CUSTOMER NAME 1'�., r f= �� �'' -�= . V� S <br />I. <br />PHONE <br />? <br />J. <br />TRANSPORTER NAME r�' `,., r ��"�` �'� � VAS <br />K. <br />PHONE L- 95 <br />L. <br />TRANSPORTER EPA IDn C A L �` ► UZ -4 C <br />M. <br />CONTACT <br />T 1: . ♦ - I/r 1/ 11 I1" � I -_j - , ( 1 . 1 _- 1 1 . I <br />is <br />E <br />F. <br />G <br />W <br />v- <br />-l__I Ir l vn r MIVML: 1p tituutJ I <br />d <br />PROFILE ❑ <br />APPROVED BY <br />GENERATOR'S CERTIFICATION <br />OTHER ❑ <br />PURCHASE ORDER OR JOB NUMBER <br />I HEREBY CERTIFY THAT THE INFORMATION PROVIDED ON THIS DOCUMENT, IS TRUE AND ACCURATE, AND NO INTENTIONAL MIS- <br />REPRESENTION HAS BEEN COMMITTED BY ANYONE. I FURTHER CERTIFY THAT ANY SAMPLE(S) PROVIDED WITH THIS WASTE <br />PROFILE WERE TAKEN AND PRESERVED IN ACCORDANCE WITH 40 CFR 261, APPENDIX 1 AND ARE ACCURATE AND REPRESEN- <br />TATIVE OF MY ACTUAL WASTE STREAM. I HEREBY AGREE TO NOTIFY DE MENNO / KERDOON SHOULD THIS WASTE STREAM <br />CHANGE IN ANY WAY. <br />AUTHORIZED SIGNATURE. DATE <br />PRINT NAME AND TITLE <br />FORM NO. 1001 REV. 1-30-95 <br />